1. Palliative Care for Heart Failure Tiffani Schmitz RN, BSN, MSM Marie Cunningham BSM

2. 2 Objectives 1.Describe the admission history and pattern of patients with end stage heart disease in the last twelve months of life as identified by research results. 2.Identify an evidence based, quantifiable measure to determine the most appropriate time to refer to palliative care or hospice care. 3.Describe key palliative interventions for patients with end stage heart disease.

3. 3 Industry Trends  Number of deaths from chronic illness is approximately 70%  NHPCO estimates nearly 41.6% of all deaths in the US were under the care of a hospice program *  Number of deaths from chronic illness is approximately 70%  NHPCO estimates nearly 41.6% of all deaths in the US were under the care of a hospice program * *NHPCO Data 2009 2,450,000 US Deaths 1,020,000 Hospice Deaths 41.6%

4. 4 US Causes of Death 2010 CDC

5. 5 Percentage of Hospice Admissions by Primary Diagnosis 2010 NHPCO Facts and Figures on Hospice Care

6. 6 Important Needs Going Unmet

7. 7 Late Referrals Undermine Hospice Value

8. 8 The 2010 HF Society of America Comprehensive HF Practice Guidelines End of Life care should be considered in patients who have advanced, persistent HF with symptoms at rest despite repeated attempts to optimize pharmacologic, cardiac device and other therapies, as evidenced by 1 or more of the following: Heart Failure Hospitalization Chronic poor quality of life with minimal or no ability to accomplish ADL’s Need for continuous intravenous inotropic therapy

9. 9 Challenges in Determining “End of Life” Difficult to put a 6 Month time frame on patients with chronic diseases Most are fairly stable Accustomed to symptom exacerbation Develop new levels of normal

10. 10 Challenges in determining “End of Life” BMJ 2000; 320: 469-473 Would I be surprised if my patient died within the next twelve months? A study that looked at physician prognostic accuracy in terminally ill patients found 63% of physicians were overly optimistic in estimating survival The closer the relationship to the patient, the longer the prognosis Overall, physicians overestimated survival by a factor of 5.3 Or 530%

11. 11 Prognosis Stays Uncertain Through Most of the Last Part of Life Days before Death Median 2-month Survival Estimate 0.0 0.2 0.4 0.6 0.8 7654321 Lung cancer Congestive heart failure * From SUPPORT, 1988-93

12. 12 The Research Can the admission history alone indicate when to refer to hospice or palliative care?Retrospectivereview of charts Adult patients who died at TriHealth died at TriHealth hospitals from a chronic illness between April 2005 and October 2004 Review of 441 cases

13. 13 Key Outcome Yes! The Admission history alone is a reliable tool to use to determine when to refer to hospice or palliative care. Keep in Mind:Recurringhospitalizations are often inconsistent with the patient’s priorities, quality of life, and wishes life, and wishes Hospice care reducesreadmissions to the hospital RecurringHospitalizations are costly to are costly to the hospital

14. 14 Financial Implications 441 patients in the study incurred a $1,700,000 loss for TriHealth Total cost less total payment Takes into consideration the direct and indirect cost of providing care

15. 15 Average Number of Admissions

16. 16 Mean Admissions for Heart Patients 22

17. 17 Cost of Readmission within 30 Days $17.4 billion spent in 2004 in the US for unplanned Medicare re-hospitalizations Approximately 28% of re-hospitalizations are avoidable $12 billion of this was for potentially preventable re-hospitalizations

18. 18 Healthcare Reform Act Patient Protection and Affordable Care Act includes Value Based Purchasing (VBP) implemented March 2010 VBP is a Medicare system that considers quality of care in determining payment to individual providers Hospitals will be penalized financially if their readmissions for heart failure, AMI, and pneumonia exceed national benchmarks

19. 19 Hospice vs. Palliative Care Curative Care Comfort Care Palliative Care Hospice Care

20. 20 Why Focus on End Stage Heart Disease? A 2008 Medpac report made recommendations to change the payment rate to hospitals with high re-admissions Patients admitted with heart failure have shorter hospital LOS, but higher rates of re-admissions within 30 days (Jama, June 2, 2010)

21. 21 Trend of the HF patient Orientation Status quo Symptom exacerbation In and out of acute care With every admission may hit ‘new normal’ but maintaining at a new low Disease is the focus Orientation Status quo Symptom exacerbation In and out of acute care With every admission may hit ‘new normal’ but maintaining at a new low Disease is the focus New Orientation New normal Most are not ready for “newness” Creating moments of joy; healing happens and may be seen as a gift and a surprise Promote openness and understanding Disease is in the background Disorientation Bad news-chaos No language Unfamiliar territory Too difficult, too hard, too scary, too visceral

22. 22 Comparing Hospice and Nonhospice Patient Survival 81 Days 39 Days 21 Days Hospice care resulted in an average increase of life by 29 days. Retrospective statistical analysis of 4493 patients from 5% of Medicare patients from 1998-2002 Connor SR et al. JPSM 2007; 33:238-46

23. 23 What does 81 days mean to your patients?

24. 24 Conversations End of Life Conversations Alone Have Positive Impact Advance cancer patients who had EOL discussions showed 35.7% in lower costs than those with no EOL discussions Those who discussed EOL showed: 1 Higher tendency to want to know life expectancy 2 Acknowledgement of terminal illness 3 Less likely to favor futile care over comfort 4 Preference to avoid dying in the ICU 5 Higher likelihood to receive outpatient hospice care and earlier referral Source: Health Care Costs in the Last Week of Life: Associations with EOL Conversations, Arch Inter Med 2009

25. 25 Rate of Readmission for Heart Failure Patients Within 30 Days Medicare data on patient discharged between July 1, 2006 and June 30, 2009. Hospitalcompare.hhs.gov HOC data from Jan 2011 though October 2011 Number of Patients 584 103403 319

26. 26 Pathways for End Stage Heart Disease Effectively manage symptoms and avoid hospital re-admissions  Nursing visits  Cardiac medications  Focus on patient and caregivers  24/7 Support Team  Meet all levels of care Implement a plan of care to create a positive and meaningful end of life experience

27. 27 Nursing Visits Tailored to meet needs of patientAggressive symptom managementEducate about disease processCreate an effective plan of care

28. 28 Medications Continue to utilize cardiac medications that are beneficial for symptom management Cardiac comfort pack (Lasix, nitroglycerin, ASA, morphine)Cardiac comfort pack (Lasix, nitroglycerin, ASA, morphine)

29. 29 Caregiver Focus Caregiver education, support and guidance Prepare for the crisis to prevent re- admissions Define patient and caregiver goals of care

30. 30 24/7 Availability Break cycle of calling 911 or returning to hospital Assure patient and family that someone will be there in a crisis Be proactive

31. 31 End of Life Program Yields Dramatic Improvement in Hospice Referrals and Hospital Admissions Source: Advisory Board, Franciscan Health System, Tacoma, Wash Goal: To identify patients early in the process so that referral to appropriate care and related community resources occurs in a timely fashion. Goal: To identify patients early in the process so that referral to appropriate care and related community resources occurs in a timely fashion.

32. 32 Meet all levels of care What happens if symptoms exacerbate? Create a plan to address acute care needs without hospitalizations Inpatient care center Continuous care Address caregiver breakdown

33. 33 Palliative Care Saves Money and Improves End of Life Experience 1 Increasing Satisfaction with Care and Lower Costs: Results of a Randomized Trial of In-Home Palliative Care JAGS, The American Geriatrics Society, 2007 Patients assigned to in-home Palliative Care were more satisfied with care 93% were very satisfied after 90 days 20% were more likely to die at home than the patients receiving usual care 13% were less likely to go to the ED or be admitted to the hospital than usual care patients 33% lower costs than patients with standard care

34. 34 Help patients understand their options Physicians have a lot of power in influencing the elderly population Most patients don’t have all the facts about hospice and palliative care They count on their doctors to tell them It is important that physicians take ownership in discussing end of life options

35. 35 Create a plan for your patients Utilize programs that can work with you to meet the needs of your patients Learn to Identify patients who meet EOL criteria Have EOL conversations with your patients or partner with someone who can help you have these conversations Advance care planning (Living Will, HCPOA, DNR)

36. Thank You (513) 891-7700